A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Document the infiltration.

Stop the infusion.

Elevate the arm.

Apply a warm compress.

Answer and Explanation

The Correct Answer is B

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

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Correct Answer is C

Explanation

The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart.

This can help alleviate dyspnea and improve oxygenation in clients with heart failure.

A. "We require informed consent for all routine treatments." B. "A family member must witness your signature on the informed consent form." C. "We can accept verbal consent unless the surgical procedure is an emergency." D. "You can sign the informed consent form after the provider explains the pros and cons of the procedure."

Correct Answer is D

Explanation

The correct answer is D. Informed consent is a process of providing information that enables the patient to make a decision to undergo a specific treatment. It requires time, patience and clarity of explanation. Consent should be obtained prior to surgery and ensure that the patient has sufficient time and information to make an informed decision. The provider should explain the indications, risks, benefits and alternatives of the procedure.

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A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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